What are the treatments for primary aldosteronism and Addison's disease?

Treatment Approaches for Primary Aldosteronism and Addison's Disease

Primary Aldosteronism Treatment

The treatment for primary aldosteronism depends on whether the condition is unilateral or bilateral, with mineralocorticoid receptor antagonists (MRAs) recommended for bilateral disease and laparoscopic adrenalectomy for unilateral disease. 1

Diagnostic Approach Before Treatment

1. Screening with aldosterone-to-renin ratio (ARR) (cutoff: ARR > 30 and plasma aldosterone ≥ 10 ng/dL)
2. Confirmatory testing with intravenous saline suppression test or oral salt-loading test
3. Adrenal CT imaging followed by adrenal venous sampling to determine if aldosterone production is unilateral or bilateral

Treatment Algorithm for Primary Aldosteronism

For Bilateral Disease (60% of cases):

• First-line treatment: Mineralocorticoid receptor antagonists 1
  • Spironolactone: Start at 12.5-25 mg daily, titrate up to 50-100 mg daily or 200 mg if necessary 1, 2
    • FDA-approved dosage for primary hyperaldosteronism: 100-400 mg daily 2
  • Eplerenone: Alternative with fewer sexual side effects, start at 25 mg daily 1
    • Less potent than spironolactone, requires twice-daily dosing

For Unilateral Disease:

• First-line treatment: Laparoscopic adrenalectomy 1
  • Improves blood pressure in virtually 100% of patients
  • Completely cures hypertension in approximately 50% of patients

For Glucocorticoid-Remediable Aldosteronism (Type 1):

• Low-dose dexamethasone (safe during pregnancy) 1

Monitoring During Treatment

• Check serum potassium and renal function within 1-2 weeks of starting treatment
• Monitor potassium at 3 days and 1 week after initiating therapy, then monthly for first 3 months
• Regular assessment of blood pressure control
• Watch for side effects: gynecomastia, sexual dysfunction, menstrual irregularities, hyperkalemia

Common Pitfalls in Primary Aldosteronism Management

• Medication interference with ARR testing (mineralocorticoid receptor antagonists, direct renin inhibitors, β-blockers)
• Risk of hyperkalemia when MRAs are combined with ACE inhibitors
• Delayed diagnosis may result in vascular remodeling causing residual hypertension even after treatment

Addison's Disease Treatment

Addison's disease (primary adrenal insufficiency) requires lifelong replacement therapy with glucocorticoids and mineralocorticoids to address cortisol and aldosterone deficiencies. 3, 4

Treatment Components:

1. Glucocorticoid Replacement:

• Hydrocortisone: 20 mg daily, divided into 2-3 doses 4
  • Morning dose should be larger to mimic natural cortisol rhythm
  • Alternative: Cortisone acetate 25 mg daily in divided doses
• Dosing should follow circadian rhythm (higher in morning, lower in evening)

2. Mineralocorticoid Replacement:

• Fludrocortisone: 0.05-0.2 mg daily 3, 4
  • FDA-approved for partial replacement therapy in primary adrenocortical insufficiency 3
  • Dose adjusted based on blood pressure, serum electrolytes, and plasma renin activity

3. Androgen Replacement (Optional):

• Dehydroepiandrosterone (DHEA) 20-50 mg daily may be considered, especially in women 4
• Evidence for benefit is limited

Monitoring Addison's Disease Treatment:

• Blood pressure (target: normal, without orthostatic hypotension)
• Serum electrolytes (sodium and potassium)
• Plasma renin activity (target: upper normal range)
• Weight (to detect fluid retention or depletion)
• Clinical symptoms (fatigue, salt craving, dizziness)

Special Considerations for Addison's Disease:

• Stress dosing: Increase glucocorticoid dose during illness, surgery, or significant stress
• Emergency kit: Patients should carry injectable hydrocortisone for emergency use
• Medical alert identification: To ensure proper treatment during emergencies

Common Pitfalls in Addison's Disease Management

• Inadequate stress dosing during illness or surgery
• Over-replacement of glucocorticoids leading to cushingoid features and bone loss
• Under-replacement of mineralocorticoids causing orthostatic hypotension and electrolyte imbalances
• Failure to educate patients about emergency management

Both conditions require careful monitoring and dose adjustments based on clinical response and laboratory parameters to ensure optimal outcomes and minimize complications.